A postsurgical client has been receiving morphine by patient-controlled analgesia for 2 days. What action by the nurse best addresses potential adverse effects?
administering a stool softener as prescribed
auscultating the client's lung for adventitious sounds
encouraging active range of motion exercises
applying calf compressors as prescribed
The Correct Answer is A
A. Administering a stool softener is essential as opioids like morphine commonly cause constipation, and this proactive measure helps mitigate that adverse effect.
B. While auscultating the lungs is important to monitor respiratory function, it does not specifically address a common adverse effect of morphine.
C. Encouraging active range of motion exercises can help prevent complications from immobility but does not directly address the most common adverse effect of morphine.
D. Applying calf compressors can help prevent deep vein thrombosis, but it is not the most effective action for addressing the specific adverse effects of morphine use.
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Correct Answer is A
Explanation
A. "There can be an unsafe reaction between your antidepressant and St. John's wort, which is why taking them both is discouraged." is correct; St. John's wort can reduce the effectiveness of SSRIs and may increase the risk of serotonin syndrome, making it vital for the nurse to address this safety concern.
B. "Herbal remedies often contain unknown doses of the desired ingredient, which can be dangerous." is a valid point, but it does not specifically address the interaction with the client’s current medication.
C. "It's very important that you not take the St. John's wort at the same time of day as your antidepressant." is misleading; the concern is not just about timing but about taking both together at all.
D. "It's very important that you comply with your prescribed treatment." while true, this response does not directly address the specific risks associated with combining St. John's wort and citalopram.
Correct Answer is A
Explanation
A. Hypocalcemia is correct because esomeprazole, a proton pump inhibitor, can lead to decreased calcium absorption, resulting in low calcium levels, which can cause muscle cramps.
B. Hyperkalemia is incorrect; while potassium levels can be affected by various medications, muscle cramps are not typically associated with high potassium levels.
C. Hypercalcemia is incorrect as it refers to elevated calcium levels, which would not cause muscle cramps and could actually lead to muscle weakness rather than cramping.
D. Hyponatremia is incorrect; low sodium levels may cause other symptoms but are not specifically linked to muscle cramps in the same way as low calcium levels are.